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Funding: This work was supported by the United Kingdom Research and Innovation (UKRI), Global Challenges Research Fund (GCRF), One Ocean Hub (Grant Ref: NE/S008950/1). The blue economy has roots in the international arena of sustainable development and sets out to unlock opportunities for economy and society whilst protecting and enhancing marine environments. To date there has been no analysis of how this overarching intention for sustainability has influenced the rapid development of blue economy policies at national and regional scales. In this article, we analyse the synergies and conflicts between blue economy policies from a diversity of national and regional policies and the UN Sustainable Development Goals. We show that to maintain critical alignment with targets for sustainability, place-based contextual development of blue economies that meet the needs of all actors is necessary. These needs relate to ensuring resilience against future environmental and political shocks, the maintenance of the ecological basis for thriving blue economies, and capacity development at all levels to support effective and equitable governance. Results indicate that co-production will be important to achieve sustainable blue economies. Publisher PDF

Background Decisions on funding new healthcare technologies assume that all health improvements are valued equally. However, public reaction to health technology assessment (HTA) decisions suggests there are health attributes that matter deeply to them but are not currently accounted for in the assessment process. We aimed to determine the relative importance of attributes of illness that influence the value placed on alleviating that illness. Method We conducted a discrete choice experiment survey that presented general public respondents with 15 funding decisions between hypothetical health conditions. The conditions were defined by five attributes that characterise serious illnesses, plus the health gain from treatment. Respondent preferences were modelled using conditional logistic regression and latent class analysis. Results 905 members of the UK public completed the survey in November 2017. Respondents generally preferred to provide treatments for conditions with ‘better’ characteristics. The exception was treatment availability, where respondents preferred to provide treatments for conditions where there is no current treatment, and were prepared to accept lower overall health gain to do so. A subgroup of respondents preferred to prioritise ‘worse’ health states. Conclusion This study suggests a preference among the UK public for treating an unmet need; however, it does not suggest a preference for prioritising other distressing aspects of health conditions, such as limited life expectancy, or where patients are reliant on care. Our results are not consistent with the features currently prioritised in UK HTA processes, and the preference heterogeneity we identify presents a major challenge for developing broadly acceptable policy.

Over four decades, China’s transformed propaganda system has embraced public diplomacy to dispel its perceived “threat.” The most recent strategy has been the branding of the Chinese Dream narrative. Although there has been some academic focus on China’s nation branding, little has been written about its reception by overseas audiences. Accordingly, this article draws on focus-group data and employs Tu Wei-ming’s “cultural China” framework in exploring how the Chinese Dream is received and interpreted in the United Kingdom. This article contributes to understandings of nation branding by recognising how Chinese diaspora communities and British intellectual and professional elites engage with and promote brand values. It argues that the socio-cultural aspect of branding is important for China’s identity and that using the Chinese Dream as a branding narrative is successful when it focuses on cultural and economic messaging but divides opinion when political ideology is used. Image © Yan Wu

Background Recruitment and retention of participants in surgical trials is challenging. Knowledge of the most common and problematic issues will aid future trial design. This study aimed to identify trial staff perspectives on the main issues affecting participant recruitment and retention in UK surgical trials. Methods An online survey of UK surgical trial staff was performed. Respondents were asked whether or not they had experienced a range of recruitment and retention issues, and, if yes, how relatively problematic these were (no, mild, moderate or serious problem). Results The survey was completed by 155 respondents including 60 trial managers, 53 research nurses, 20 trial methodologists and 19 chief investigators. The three most common recruitment issues were: patients preferring one treatment over another (81·5 per cent of respondents); clinicians' time constraints (78·1 per cent); and clinicians preferring one treatment over another (76·8 per cent). Seven recruitment issues were rated moderate or serious problems by a majority of respondents, the most problematic being a lack of eligible patients (60·3 per cent). The three most common retention issues were: participants forgetting to return questionnaires (81·4 per cent); participants found to be ineligible for the trial (74·3 per cent); and long follow‐up period (70·7 per cent). The most problematic retention issues, rated moderate or serious by the majority of respondents, were participants forgetting to return questionnaires (56·4 per cent) and insufficient research nurse time/funding (53·6 per cent). Conclusion The survey identified a variety of common recruitment and retention issues, several of which were rated moderate or serious problems by the majority of participating UK surgical trial staff. Mitigation of these problems may help boost recruitment and retention in surgical trials., An online survey of surgical trial staff was conducted to identify key issues affecting recruitment and retention of participants in UK surgical trials. Several issues were reportedly experienced by over 70 per cent of respondents. Seven recruitment and two retention issues were rated ‘moderate’ or ‘serious’ by a majority of respondents. Lack of equipoise a common theme

Quality learning for sustainability can have a transformative effect in terms of promoting empowerment, leadership and wise investments in individual and collective lives and regenerating the local economies of cities, making them more inclusive, safe, resilient and sustainable. It can also help cities move towards achieving the United Nations Sustainable Development Goals (SDGs). Effecting the transformation of cities into Learning Cities, however, requires changes in the structure of governance. Drawing on interviews with key informants as well as secondary data, this article examines how collaborative governance has facilitated quality learning for sustainability in Bristol (United Kingdom), Kitakyushu (Japan) and Tongyeong (Republic of Korea). Focusing on a conceptual framework and practical application of learning initiatives, this comparative study reveals how these cities’ governance mechanisms and institutional structures supported initiatives premised on cooperative learning relationships. While recognising differences in the scope and depth of the learning initiatives and the need for further improvements, the authors found evidence of general support for the governance structures and mechanisms for learning in these cities. The authors conclude by recommending that (1) to implement the Learning Cities concept based on UNESCO’s Key Features of Learning Cities, recognition should be given to existing sustainability-related learning initiatives in cities; (2) collaborative governance of the Learning Cities concept at both local and international levels should be streamlined; and (3) UNESCO’s Global Network of Learning Cities could serve as a hub for sharing education/learning resources and experiences for other international city-related programmes as an important contribution to the implementation of the SDGs.

Background Policies such as the Cancer Drugs Fund in England assumed a societal preference to fund cancer care relative to other conditions, even if that resulted in lower health gain for the population overall. Objective The aim of this study was to investigate the evidence for such a preference among the UK public. Methods The MEDLINE, PubMed and Econlit electronic databases were searched for studies relating to preferences for prioritising cancer treatment, as well as studies relating to preferences for the characteristics of cancer (severity of disease, end-of-life). The searches were run in November 2015 and updated in March 2017. Empirical preference studies, studies of public views, and studies in English were included. Results We identified 24 studies relating to cancer preferences. Two directly addressed health trade-offs in the UK—one showed a preference for health gain in cancer, while the other found no such preference but provided results consistent with population health maximisation. Other studies mostly showed support for cancer but did not require a direct health trade-off. Severity and end-of-life searches identified 12 and 6 papers, respectively, which were additional to existing reviews. There is consistent evidence that people give priority to severe illness, while results for end-of-life are mixed. Conclusion We did not find consistent support for a preference for health gains to cancer patients in the context of health maximisation. The evidence base is small and the results are highly sensitive to study design. There remains a contradiction between these findings and the popular view of cancer, and further work is required to determine the features of cancer which contribute to that view. Electronic supplementary material The online version of this article (doi:10.1007/s40273-017-0511-7) contains supplementary material, which is available to authorized users.

Healthy marine ecosystems provide a wide range of resources and services that support life on Earth and contribute to human wellbeing. Marine Protected Areas (MPAs) are accepted as an important tool for the restoration and maintenance of marine ecosystem structure, function, health and ecosystem integrity through the conservation of significant species, habitats, or entire ecosystems. In recent years there has been a rapid expansion in the area of ocean designated as an MPA. Despite this progress in spatial protection targets and the progressive knowledge of the essential interdependence between the human and the ocean system, marine biodiversity continues to decline, placing in jeopardy the range of ecosystem services benefits humans rely on. There is a need to address this shortcoming. Ambitious marine conservation: � Requires a shift from managing individual marine features within MPAs to whole-sites to enable repair and renewal of marine systems; � Reflects an ambition for sustainable livelihoods by fully integrating fisheries management with conservation (Ecosystem Based Fisheries Management) as the two are critically interdependent; � Establishes a world class and cost effective ecological and socio-economic monitoring and evaluation framework that includes the use of controls and sentinel sites to improve sustainability in marine management; and � Challenges policy makers and practitioners to be progressive by integrating MPAs into the wider seascape as critical functional components rather than a competing interest and move beyond MPAs as the only tool to underpin the benefits derived from marine ecosystems by identifying other effective area-based conservation measures (OECMs) to establish synergies with wider governance frameworks.

Seagrass beds are critically important habitats delivering a range of ecosystem service benefits that support human wellbeing. They are, however, declining globally at an unprecedented rate. The damaging effects on Zostera marina (Common Eelgrass) seagrass beds in UK waters from mechanical recreational boating activities, namely anchoring and traditional swing mooring scour, suggest that measures of implementing management to mitigate human impacts need prioritising. Eco-moorings, a design that reduces the abrasion pressure of anchoring and mooring on the seabed, are such a mitigation method. In the UK, limited test sites and a lack of social acceptance of the technology compounds the limited uptake of eco-moorings to date. To advance the evidence base, this study focusses on a bespoke eco-mooring design deployed in 2017 to protect seagrass beds within a popular anchorage in Southwest England. We assess the behavioural and social responses of recreational boaters to the trial eco-mooring through 1) mapping of boating activity pre- and post-deployment and 2) structured questionnaires both on-site and online to local and national audiences respectively. Results of mapped boating activity demonstrated a shoreward distribution shift of anchoring away from the deployed eco-mooring, with 45.4% of all anchoring vessels directly within or within a range of potential influence of the seagrass bed. Through the deployment of the eco-mooring (where no mooring previously existed), an estimated additional 20% of anchoring pressure was alleviated from the seagrass bed. A total of 89.6% of on-site respondents reacted positively to the prospect of further eco-moorings being deployed locally. When questioned, 74.6% of on-site and 82.8% of online respondents demonstrated a preference for the physical action of mooring a vessel over anchoring. This suggests that implementation of eco-moorings in seagrass-dense regions could successfully alleviate anchor damage, especially where over half of respondents indicated an awareness of seagrass presence prior to anchoring their vessel and/or hesitance to cease visiting preferential anchoring sites (sheltered bays). This study recommends targeting conservation guidance at the powerboat community, the dominant group anchoring/mooring in the study area and identified as not currently engaged in seagrass education campaigns. It is proposed that management introduce incentives such as free of charge eco-moorings and/or anchoring charges in Marine Protected Areas/Voluntary No Anchor Zones to conserve and recover seagrass and other sensitive seabed habitats nationally.

This paper uses a macro, meso- and micro-level analysis of employability best practice in higher education institutions (HEIs) to question how employability is being conceived within higher...

OBJECTIVE To investigate the impact of patient and public involvement (PPI) on rates of enrolment and retention in clinical trials and explore how this varies with the context and nature of PPI. DESIGN Systematic review and meta-analysis. DATA SOURCES Ten electronic databases, including Medline, INVOLVE Evidence Library, and clinical trial registries. ELIGIBILITY CRITERIA Experimental and observational studies quantitatively evaluating the impact of a PPI intervention, compared with no intervention or non-PPI intervention(s), on participant enrolment and/or retention rates in a clinical trial or trials. PPI interventions could include additional non-PPI components inseparable from the PPI (for example, other stakeholder involvement). DATA EXTRACTION AND ANALYSIS Two independent reviewers extracted data on enrolment and retention rates, as well as on the context and characteristics of PPI intervention, and assessed risk of bias. Random effects meta-analyses were used to determine the average effect of PPI interventions on enrolment and retention in clinical trials: main analysis including randomised studies only, secondary analysis adding non-randomised studies, and several exploratory subgroup and sensitivity analyses. RESULTS 26 studies were included in the review; 19 were eligible for enrolment meta-analysis and five for retention meta-analysis. Various PPI interventions were identified with different degrees of involvement, different numbers and types of people involved, and input at different stages of the trial process. On average, PPI interventions modestly but significantly increased the odds of participant enrolment in the main analysis (odds ratio 1.16, 95% confidence interval and prediction interval 1.01 to 1.34). Non-PPI components of interventions may have contributed to this effect. In exploratory subgroup analyses, the involvement of people with lived experience of the condition under study was significantly associated with improved enrolment (odds ratio 3.14 v 1.07; P=0.02). The findings for retention were inconclusive owing to the paucity of eligible studies (odds ratio 1.16, 95% confidence interval 0.33 to 4.14), for main analysis). CONCLUSIONS These findings add weight to the case for PPI in clinical trials by indicating that it is likely to improve enrolment of participants, especially if it includes people with lived experience of the health condition under study. Further research is needed to assess which types of PPI work best in particular contexts, the cost effectiveness of PPI, the impact of PPI at earlier stages of trial design, and the impact of PPI interventions specifically targeting retention., JC, SPZ, and JH were supported by the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC). IRC was supported by the University of Oxford Returning Carers Fund. The funders were not involved in the study design; data collection, analysis, or interpretation; or writing the report. All authors had full access to all of the data in the study and can take responsibility for the integrity of the data and accuracy of the data analysis. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

BACKGROUND Demands on health services across are increasing because of the combined challenges of an expanding and aging population, alongside complex comorbidities that transcend the classical boundaries of modern health care. Continuing to provide and coordinate care in the current manner is not a viable route to sustain the improvements in health outcomes observed in recent history. To ensure that there continues to be improvement in patient care, prevention of disease, and reduced burden on health systems, it is essential that we adapt our models of delivery. Providers of health and social care are evolving to face these pressures by changing the way they think about the care system and, importantly, how to involve patients in the planning and delivery of services. OBJECTIVE The objective of this paper is to provide (1) an overview of the current state of Internet of Things (IoT) and key implementation considerations, (2) key use cases demonstrating technology capabilities, (3) an overview of the landscape for health care IoT use in Oxford, and (4) recommendations for promoting the IoT via collaborations between higher education institutions and industry proof-of-concept (PoC) projects. METHODS This study describes the PoC projects that will be created to explore cost-effectiveness, clinical efficacy, and user adoption of Internet of Medical Things systems. The projects will focus on 3 areas: (1) bring your own device integration, (2) chronic disease management, and (3) personal health records. RESULTS This study is funded by Research England’s Connecting Capability Fund. The study started in March 2018, and results are expected by the end of 2019. CONCLUSIONS Embracing digital solutions to support the evolution and transformation of health services is essential. Importantly, this should not simply be undertaken by providers in isolation. It must embrace and exploit the advances being seen in the consumer devices, national rollout of high-speed broadband services, and the rapidly expanding medical device industry centered on mobile and wearable technologies. Oxford University Hospitals and its partner providers, patients, and stakeholders are building on their leading position as an exemplar site for digital maturity in the National Health Service to implement and evaluate technologies and solutions that will capitalize on the IoT. Although early in the application to health, the IoT and the potential it provides to make the patient a partner at the center of decisions about care represent an exciting opportunity. If achieved, a fully connected and interoperable health care environment will enable continuous acquisition and real-time analysis of patient data, offering unprecedented ability to monitor patients, manage disease, and potentially deliver early diagnosis. The clinical benefit of this is clear, but additional patient benefit and value will be gained from being able to provide expert care at home or close to home. INTERNATIONAL REGISTERED REPOR DERR1-10.2196/12077

1. Marine Protected Areas (MPAs) and networks of MPAs are being implemented globally as a spatial management tool for achieving conservation objectives. There has been considerable progress in reaching the prescribed 10% protected area target for 2020, outlined in the Convention on Biological Diversity Aichi Target 11 and the United Nations Sustainable Development Goal 14. 2. The application of MPA network design principles (e. g. Representative, ecological connectivity), which underpin ecological coherence, is still lacking or insufficient in many regions. Poor ecological coherence hinders the ecological performance of MPA networks, leading to dysfunction in the flow of ecosystem services and reduced ecosystem benefits, with potentially negative consequences for human well-being. 3. This paper presents four pivotal focus points for future progress that can bridge the gap between ecological and social systems. The aim is to shift the discourse of ` ecological coherence' further into the social sphere, and hence support the alignment of the process of designating ecologically coherent MPA networks with the ` triple bottom line' of economic development, environmental sustainability, and social inclusion, as described in the Sustainable Development Goals (SDGs), to achieve social-ecological coherence in MPA network design.

Background Evidence-based medicine (EBM) is maturing from its early focus on epidemiology to embrace a wider range of disciplines and methodologies. At the heart of EBM is the patient, whose informed choices have long been recognised as paramount. However, good evidence-based care is more than choices. Discussion We discuss six potential‘biases’ in EBM that may inadvertently devalue the patient and carer agenda: limited patient input to research design, low status given to experience in the hierarchy of evidence, a tendency to conflate patient-centred consulting with use of decision tools; insufficient attention to power imbalances that suppress the patient’s voice, over-emphasis on the clinical consultation, and focus on people who seek and obtain care (rather than the hidden denominator of those that do not seek or cannot access care). Summary To reduce these‘biases’, EBM should embrace patient involvement in research, make more systematic use of individual (‘personally significant’) evidence, take a more interdisciplinary and humanistic view of consultations, address unequal power dynamics in healthcare encounters, support patient communities, and address the inverse care law

Aim: To systematically collate, appraise and summarise systematic reviews that assess the effects of exercise on non-specific low back pain (NSLBP). Method: A systematic review of electronic databases was carried out from January 1965 to April 2008. Hand searching and screening of reference lists was also undertaken. Two reviewers worked independently throughout all stages of the review and agreement was achieved by consensus. Strict inclusion/exclusion criteria were applied based on standard definitions of key terms. Data from included studies were abstracted onto a pre-tested standardised form. Quality was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) checklist for systematic reviews. Results: Four reviews met the inclusion criteria. Three of these achieved a low bias rating indicating a moderate/good quality review in which some/most of the SIGN criteria were fulfilled. These studies provide strong prima facie evidence that exercise programmes reduce sick leave and impr...

Objective In-treatment and post-treatment outcomes were compared for three detoxification procedures (lofexidine + naloxone, lofexidine + placebo naloxone, and methadone). Sample and design The sample was 137 opiate dependent in-patients. Detoxification treatments were 6-day lofexidine + naloxone ( n = 45), lofexidine + placebo naloxone ( n = 46), or 10-day methadone reduction ( n = 46). A cohort study design was used with double-blind random allocation to lofexidine + naloxone versus lofexidine + placebo. Patients who did not consent to, or who were excluded from randomisation received methadone. Results Outcome differences between treatment groups at follow-up were generally associated with length of stay post-detoxification rather than detoxification procedure. Among patients who were not opiate abstinent throughout follow-up ( n = 85), those who received lofexidine + naloxone detoxification reported a longer interval to first heroin use, with an interaction between detoxification medication and subsequent retention in treatment also identified. Conclusions Detoxification medication may influence medium-term opiate use outcomes via its effect upon retention in treatment.

The article uses a semi-structured interview method to assess the acquisition, preparation and use of heroin in a cohort of 114 drug users in contact with treatment services in south-east London, and examines the impact of the increase in crack availability on heroin use and preparation in this population. Seventy-six participants reported using heroin on a daily basis, involving an average of 2.8 hits and using a mean of 0.75 g on each using day. Although almost all of the sample bought their own heroin, very few were confident of assessing its quality, and the mean estimated purity level of heroin bought was 22.7%. Similarly, most of the sample believed that the heroin purchased was adulterated and, although most believed that the heroin quality was evident during the preparation stage, relatively few would ask about quality at the point of purchase, and it is apparent that the beliefs held by much of the sample about drug purity issues did not impact upon their behaviour. Seventy individuals reported t...

Sleep disturbance experienced during methadone or lofexidine opiate detoxification was investigated in 118 opiate-dependent patients receiving inpatient detoxification treatment. Sleep was assessed at four time-points during opiate detoxification using a self-report questionnaire. Maximum sleep disruption occurred at completion of detoxification and during the protracted withdrawal period, with patients in the methadone group reporting higher levels of withdrawal symptoms, lower overall sleep, longer sleep latencies and significantly longer periods of time awake than lofexidine patients. Regression analyses demonstrated a significant relationship between sleep disturbance, protracted withdrawal and retention in treatment, in addition to the major treatment benefit of reduced sleep disturbance conferred by lofexidine treatment.

One hundred and eight opiate addicts attending an in-patient opiate treatment unit were interviewed, using a mixed quantitative–qualitative approach, to investigate their experiences of witnessing overdoses, the associated interpretations and perceived cause of the overdose. Poly drug use and frequency of witnessed overdose was high among the sample. Use of 14 different combinations of drugs were reported, 8 of which involved the use of alcohol, and 7 benzodiazepines. Perceived cause of overdose involved attributions relating to the use of alcohol, in particular strong lager, small quantities of heroin and low levels of current opiate tolerance. Peer initiated resuscitation techniques revealed a range of responses from the probably valuable (recovery position, summon ambulance, administer naloxone) to the ineffective or frankly harmful (injecting with salt solution, immersing in a cold bath). The findings highlight the need for an overdose prevention program during in-patient detoxification and rehabilitation.

One hundred and sixteen opiate addicts attending treatment services in south London were interviewed about their drug use patterns. In the month before interview, 90% reported heroin use, while 60% had used crack cocaine and 58% alcohol. In the same period, 70% of participants reported multiple drug use, particularly concurrent heroin and crack cocaine use. Of the patients who reported using other drugs with heroin, two-third used crack cocaine, 11% diazepam, 9% methadone and 8% cocaine powder. Twenty-six per cent of crack users sample had injected crack cocaine, which provides confirmation of the increasing prevalence of this recent trend in studies using similar samples. Male participants were significantly more likely to use benzodiazepines with heroin, while women were more likely to use crack alongside heroin (and used larger quantities). These findings have implications for the treatment and management of multiple drug users, for whom opiates may be only a part of their drug-using repertoire.

(2010). Cilgerran Castle (Illus 13–14) Archaeological Journal: Vol. 167, South-West Wales: Pembrokeshire and Western Carmarthenshire, pp. 33-35.